« AnteriorContinuar »
collects, is the only mode at present known by which a permanent cure of spina bifida may be effected. Sir Astley Cooper used a needle for this purpose, though this method will not always succeed, as the fluid is so thick that it cannot pass through so small an aperture; under these circumstances it will be necessary to make a valvular opening in the parietes with a lancet, and when the fluid is evacuated, to close up the lips of the wound with adhesive plaster, so as to heal it up by the first intention. By this means also the air will be excluded, which is of the utmost consequence, for it has been observed that in almost all those cases in which the tumor has burst of its own accord, or the wound has not healed, the air being admitted, the patients have died very soon after ;-a proof how necessary it is to use every precaution to prevent its entrance. After having evacuated the tumor, a soft linen compress should be laid upon it, and straps of adhesive plaster applied over this, so as to make gentle pressure, and a roller wound lightly round the body at first; and this pressure should be gradually increased till at length a truss may be applied, as in Sir Astley Cooper's cases. If, however, as frequently happens, convulsions are caused, or any other bad symptom produced, then pressure should be applied only to that degree the patient can bear. The tumor should be punctured every, every other, or every third, fourth, or fifth day, or indeed as often as the fluid collects; and it is advisable that this should be done before it arrives at its original size, for by the constant stretching of the skin it might lose its power of contractility, and the cure be retarded, or perhaps totally prevented." 42.
The general health of the patient should be attended to by general measures, dietetical and medical. The succeeding cases are intended to illustrate the palliative treatment and spontaneous cure of spina bifida. The palliative treatment, compression, produces general thickening of the parietes of the tumour, but exerts no further influence on its contents. The spontaneous cure is effected by the tumour becoming so large, that its distended parietes inflame, ulcerate in one or more parts, and so give issue to the contents. The walls then collapse-the aperture through which the fluid passes is closed by lymph and heals-the tumour again becomes distended and bursts-the parietes again collapse-and the wound heals again as before. This process is repeated as often as the tumour fills, and, during this time, coagulated lymph is thrown out from its internal surface, the walls become successively thickened, and at length they are consolidated. This process gave the hint on puncturing, which was adopted by Messrs. Abernethy and Cooper. But this remains to be observed :—when spina bifida is cured by art, hydrocephalus frequently ensues; when spontaneously cured in the manner described, Nature leaves an aperture covered by vesicles on the top of the tumour, and communicating with the canal. When fluid collects the vesicles burst, and it thus escapes, and obviates the danger of hydrocephalus. The rupture of the vesicles undergoes exactly the same process as the rupture of the tumour-they are distended, burst, and heal. is a question whether, after spontaneous or artificial cure, the deficiency of bone is ever supplied by new osseous deposition. In general, it appears that it is not, and we possess no positive evidence to prove that it ever is so. We may now proceed to mention other cases.
Case 2. Alfred Church, aged two years and three months.
"There is situated on the lower part of the back, over the inferior lumbar vertebræ and superior portion of the sacrum, a tumor of firm consistence and of rather unequal surface, about the size of half an orange; it is moveable, and of
a darker colour than the adjacent integuments; when pressed upon or moved, the fæces are instantly evacuated. The spine, above the tumor, is slightly curved outwards; the inferior extremities are singularly deformed, and can be twisted almost in any direction; the flesh is flabby. When sitting, the right leg rests on the outer or fibular side, and with the thigh forms nearly a semicircle; the left leg rests on the inner or tibial side, and the toes of both feet point to the right. The head is scarcely enlarged, and the skull is firmly ossified, except at the anterior fontanelle. His faculties are good, and he has only as yet cut six teeth. The testes still remain in the abdomen. The urine dribbles away as fast as secreted, and causes an excoriation of the prepuce and scrotum. He was born with an imperforate anus; an artificial opening was made into the rectum, through which the fæces are now voided. The nates are not, as usual, separated by a sulcus or division, but present a continuous surface. At the time of birth (which occurred between the seventh and eighth month) his mother states that there was a large soft tumor or bag occupying the site of the present tumor, and hanging considerably over the nates; his head was greatly enlarged (nearly as big as the rest of the body) and the integuments of the forehead hung over the face. The accoucheur made several punctures in the bag, and discharged much fluid; the contents were four times subsequently evacuated, at the interval of two or three days; the sac then sloughed off, and the fæces were evacuated through the ulcerated opening. The intestines could be seen through it. During the progress of the healing of this sore, much fluid constantly drained off for some months, and the size of the head gradually diminished, and now there are small vesicles on the top of the tumor, which occasionally break, and discharge a thin limpid fluid, and then heal. His mother attributes the malformation of his head and back to a fall she received when nearly three months gone with child, by which she struck the corresponding parts of her own body, and the deformity of the inferior extremities to her having been frightened, and thrown down, about a week afterwards, by a man who had a similar deformity of legs. After this she suffered greatly during the remainder of her pregnancy with severe pains in the head and back, and the weakness of her legs was so great as to prevent her standing.
This case is perhaps the most remarkable that ever occurred of spina bifida, as it combines in it almost all the facts of importance that have ever been recorded, both by the ancients as well as the moderns; first as to the immense size of the tumor;-secondly, as to its combinations; there was hydrocephalus of great magnitude—deformed limbs-deficiency of the nates, with imperforate anus, and diminished nervous power;-thirdly, as to the progress of ossification of the vertebræ; the rings were not only defective, but the bodies also, and the intestines could be seen through the tumor which communicated with them, as the fæces were evacuated through it ;—fourthly, as to the subsidence of the hydrocephalus when the tumour sloughed off-the possibility of which fact has been doubted ;-fifthly, as to the reason suggested by the mother for the origin of the disease;-sixthly, as to the spontaneous cure-another fact hardly credited ;—and seventhly, as to its present state and the age of the patient." 51.
Case 3. May 4th, 1826. This child is four years and a half old, stout and healthy. Over the third lumbar vertebra is a tumour, equal in size to a pullet's egg, with rather a broad base, inflamed appearance, feeling solid, not diminishing on pressure, with a constant discharge of a watery fluid from an aperture situated on the top of it. The child suffers no inconvenience, and plays like other children. All that could be learned from the parents was, that the infant was born with a tumour like a bladder on the loins, that it grew, and in a few months burst. After this, the walls became thickened and hardened, and a watery fluid was constantly discharged from it. The child is now nine years old.
"There is a degree of disfiguration and swelling of the dorsal vertebræ and the integuments have ulcerated. The ulcer is as big as a shilling, but ovalshaped, and the surrounding integuments are purple. No spinous processes can be felt, and the transverse ones are widely separated, leaving a hollow cavity, over which the ulcerated integuments are stretched. During the first two weeks after the child's birth the inferior limbs were perfectly motionless, but since that period the toes have begun to move, and their motion has daily increased; so that if the sole of the foot be now tickled, it is very perceptibly felt. When the child was born, the mother describes the swelling to have had the appearance of a bladder filled with water. She did not perceive the precise time when the fluid was evacuated, but in a few days it appeared more flattened, and the ulceration then commenced. The child has all the appearances of health. The ossification of the occipital bone has been remarkably imperfect, not being larger than a shilling; so that the contents of the cranium, from their gravity and want of resistance, give the head a very oval form." 54.
The ulcer was dressed simply, and pasteboard applied to the head. The sore healed, and the spinal cavity became covered with a firm skin. Hydrocephalus now came on, and the child died with its usual symptoms. On dissection, the cranium was found very considerably increased in its dimensions, the ventricles so much distended with water, that in some places the medullary matter forming their walls was altogether wanting. The brain was very firm; on the choroid plexus was a fine hydatid. On examining the tumour of the back, the spinal canal was obliterated, excepting a small portion where the separation of the vertebræ commenced. The integuments were adherent.
We have dedicated more space to the consideration of this part of the volume, than practical men might, perhaps, deem necessary. But the nature and treatment of spina bifida are not so well understood as they should be; and possibly the information actually obtained is not universally diffused. Any little addition to our knowledge is, therefore, desirable on the one hand, and a free dissemination of it is useful on the other. The following short summary may be added.
"As the radical cure of spina bifida is always attended with some degree of danger, there are, perhaps, some cases where we should not be warranted in attempting it. If the tumor is small, and does not increase in size-if its parietes are not inflamed, and it is not painful-if the health of the patient be good, and he suffers no inconvenience from it-then, perhaps, the palliative treatment may be most judicious; but if, on the other hand, the tumor is increasing in size, or its walls are inflamed or painful, or the constitution is suffering from local irritation, the radical treatment for the cure of this disease is most advisable.
There are some cases where, from bad symptoms and a complication of diseases, there is scarcely any hope of cure; such as when they are accompanied with hydrocephalus, bursting of the tumor, and paralysis of the lower extremities. It is true that in two former instances a cure has been effected, but they may be almost considered as exceptions to a general rule. In these cases, where the patient cannot recover, the only course is to use palliatives, and to make the way as easy as possible to the grave." 56.
ON THE INJURIES OF THE SPINE.
Much has been said on these injuries by experienced surgeons, and few
in the ordinary pursuits of their profession fail to meet with cases of the kind occasionally. It is incumbent on practitioners to understand their nature and treatment. The chief injuries of the spine are concussion-fracture-dislocation.
Concussion. In complete concussion we have complete paralysis of the parts supplied by the nerves which arise below the affected portion of the medulla. In partial concussion the corresponding paralysis is partial, and in cases of this kind we find many singularities, if not anomalies. Of the possibility of meeting with such the surgeon should be aware. An explanation seems to offer itself in the supposition that the medulla may be more or less generally shaken, and in addition to this, that the origins of particular nerves may be more particularly injured. Thus occasionally there is paralysis of parts above the injury, as well as below it. This is explicable on the first supposition. Mr. Stafford mentions this case. A man received a violent kick from a horse on the most projecting point of the dorsal vertebræ. He was immediately paralysed in the lower extremities, and the arms lost all power of motion with partial loss of sensation. Under such circumstances, the upper extremities usually suffer less than the lower at the time, and recover with more rapidity. All the parts below the injury are not always paralysed; of this Mr. Stafford mentions an instance.
Case. A pack of goods struck a man between the scapula, at about the seventh cervical and first and second dorsal vertebræ; the arms were immediately and totally paralysed, and there was partial loss of power in the muscles of respiration. Neither the inferior extremities, the bladder, nor rectum were at all affected. Probably the origins only of the nerves supplying the arms were injured. We had under our charge at St. George's Hospital a case of partial paralysis from concussion of the spine.
Case. A young woman was flung out of window by her gallant. She was admitted into the hospital immediately afterwards, complaining of great pain in the dorsal and lumbar region, and loss of power over one lower extremity. Next morning there was loss of power of motion in the thigh, and numbness in the natis of that side. There was paralysis of the bladder, and great torpor of the rectum. Under cupping and antiphlogistic treatment these symptoms were in a few days nearly removed. The following is a curious case, though not fairly introduced under the head of concussion. "Oct. 1831.-About eight years from the above date, a mau, belonging to the town of Penkridge, in Staffordshire, fell from the top of a waggon-load of hay. He was taken up in a perfectly helpless state, and was immediately carried to bed: he had struck his back upon the second, third, and fourth lumbar vertebræ, which were considerably displaced laterally, the body leaning to the right side, leaving but little doubt that the spine at that part had suffered fracture. He was perfectly paralysed below the injury; the fæces escaped involuntarily, and the bladder could not expel its contents; the arms likewise were partially paralysed, in both the powers of feeling and motion. The treatment of the case I am unacquainted with, but he has kept his bed ever since, and his present state is as follows :-The muscles of the right arm are so contracted that it is closely fixed to the side; the forearm from the same cause, rests upon the humeral part; the wrist is bent on the forearm, and the fingers are firmly
clenched in the palm of the hand: the sense of feeling also is partially lost; the left arm is affected in the same manner, but not in so great a degree; the right leg has both the power of motion and feeling; the left leg has the power of feeling, but not that of motion; the sphincter muscle of the rectum remains paralysed, the fæces still escaping involuntarily, and the bladder only expelling half its contents." 61.
We proceed to Mr. Stafford's description of the effects of concussion of the spine.
"The patient immediately after the injury, as in all cases where the nervous system has received a violent shock, becomes almost lifeless-a marble coldness pervades the whole frame, but more particularly the paralysed limbs. He cannot lie in any other position than on his back ;-his pulse is weak and faltering; and he is frequently almost unconscious of what is passing around him. In fact the whole frame is in a state of collapse: in this situation he remains for a few hours, when reaction gradually commences. The warmth of the body returns until it amounts to a state of fever. The pulse rises, becoming quick, hard, and full; the tongue is furred, and great thirst is felt. The patient has more or less pain in the injured part, and sometimes delirium supervenes. If the injury be received high up, there is dyspnoea, in consequence of the muscles of respiration being paralysed, and, as I have before stated, the parts below suffer paralysis, according to where the injury was received.
Although the above symptoms commonly happen, yet they do not invariably occur; the pulse does not always become quickened, nor does it always become increased in fulness; it not unfrequently remains stationary without any perceptible change from the natural standard of health: it sometimes even becomes slower than natural, being reduced in beat as low as 60, or even as 40. The temperature of the body likewise does not always increase; the animal heat may be much the same as before the accident took place. In many instances also, if a thermometer be applied to the paralysed extremities, they will be found to be some degrees lower in temperature than those which do not suffer from the injury.
There are other symptoms besides the above consequent upon injuries of the spine. The bladder is not only paralysed, but the urine contained in it generally becomes decomposed, and foetid and calcareous matter is frequently deposited. From this cause the mucous surface often inflames and ulcerates, by which the death of the patient is accelerated. This is a very curious fact; for it would appear from such a circumstance that the nerves of the organ had some influence over its contents. Thus, if from any cause the bladder loses its power, from a deficiency of nervous influence, the urine immediately upon being secreted from the kidney, undergoes, in some measure, that change which it would do when it has entirely passed from the body. It would seem therefore, that when the energy of this organ is diminished or entirely lost, that it resembles in some degree an inanimate vessel. It would not be possible to account for these symptoms unless the nerves had some power over the contents of this organ, which would prevent decomposition." 65.
This is not only an imperfect, but an erroneous description of the alterations which take place in the urine and urinary organs. From Mr. Stafford's observations the inexperienced reader would be led to imagine that all the changes in the urine occur in the bladder, from the loss of its regulating or antiseptic powers. Mr. Stafford does not mention the alkalescence of the urine, which does, however, in general, take place. Now the urine, in many cases at the very least, becomes alkaline or is secreted so in the kidney, and that this is the case in the present class of instances is